In previous blog posts, we have described how Access + Opportunity = Drug Diversion™ in healthcare facilities in the United States. But healthcare is vastly different north of the border in Canada, and the risk points for drug diversion are different as well. Recently I was working with a client in Canada and we had the opportunity to interview Canadian Registered Nurses about their controlled substance practices. This blog presents a few observations for increased risk of drug diversion in Canadian hospitals.
There are significant differences between the US and Canada for available controlled substance product forms. In the US we are accustomed to using prefilled syringes and cartridges for many of the controlled substances (morphine, Dilaudid, meperidine, etc.) with a wide range of dosages. Access to large volume or highly concentrated product forms are typically restricted to pharmacy staff in the US, and not stored on the nursing unit. There are no prefilled cartridges or syringes for controlled substances in Canada. Controlled drugs are available in vials or ampules, with limited concentrations. There are only three concentrations of morphine available: 2 mg/mL, 10 mg/mL, or 15 mg/mL. Dilaudid is available in 2 mg/mL vials as well as 10 mg/ml vials. Highly potent product forms such as Dilaudid HP (10mg/mL) may be stored in the same cupboard with Dilaudid 2 mg/mL. Fentanyl is widely used for intermittent and continuous infusions, and the large volume product forms (20 mL vials, 50 mL vials) may be stored on the nursing units if the nurses are compounding infusions. Standards of practice vary from province to province, with less regulatory controls as in the States.
The safe preparation and administration of controlled drugs has been a topic of discussion for many years. The Institute for Safe Medication Practices (CA) has published guidelines about narcotics in Ontario and includes the following for Storage and Standardization:
- Remove the following stock items from patient care areas:
- Dilaudid ampoules or vials with concentrations greater than 2 mg/ml (exceptions in palliative care)
- Morphine ampoules or vials with concentrations greater than 15 mg/mL
- Morphine ampoules or vials with concentrations greater than 2 mg/mL in paediatric care areas
- Sufentanil (exceptions may include Operating Room and Labour and Delivery)
- Assess risk associated with narcotic stock in patient care areas
- Restrict as much as possible the admixing of narcotic solutions outside of pharmacy
- Standardize infusion concentrations of parenteral narcotic medications and selection of medications for pain management.
We asked the Canadian nurses to tell us about their use of morphine, Dilaudid and fentanyl. Which drug was prescribed IV most often, what was the most common IV dose ordered, how was the IV dose prepared, and how did they manage security of controlled drugs. The formal report from this survey will be reported elsewhere. What was more interesting was what we did not ask.
Controlled Drug Security
Not all hospitals use automated dispensing units to store and manage controlled substances. Some hospitals use sophisticated double lock cabinets, and some are still under lock and key. Most hospitals stock morphine 10 mg/mL vials. The nurses described in detail how they would dilute the morphine or Dilaudid with saline (using either a vial or 10 mL prefilled flush syringe) to achieve a lesser concentration. If the patient was given less than the full amount, the partial dose was not wasted. Instead, the nurse would hide it in the patient room, put it in a locked drawer or carry it on her person. The same syringe would be used for multiple doses to the same patient throughout the shift. At the end of the shift, the syringe was either wasted with the oncoming nurse, or passed to the next shift. Without exception, the nurses noted that this was NOT acceptable, but with cost pressures, they felt compelled to save money where possible. Many nurses noted that this was risky behavior, not just as an unsafe injection practice, but also the risk of diversion. Once the controlled drug was removed from secured storage, the prepared syringe creates a significant opportunity for tampering and diversion.
High Alert Medications
The nurses also described situations where they have access to concentrated forms of morphine, Dilaudid and fentanyl that are still stored on the nursing units. The main reason for this was because pharmacy was not available to compound infusions when needed. Infrequently we heard that the hospital provided compounded infusions from outside sources or the pharmacy. Carrying multiple concentrations for high-risk drugs is a well-established risk factor for patient harm, clearly described in a recent Canadian medical journal.[i] The force of regulatory compliance may decrease the amount of compounding outside the pharmacy when the National Association of Pharmacy Regulatory Authorities (NARPA) guidelines for sterile compounding go into effect in each province.
While controlled drug injections are predominately IV in the US, there are other novel practices in Canada. The nurses described procedures for subcutaneous injections of Dilaudid. In some hospitals this was the preferred route to mitigate the risks associated with the use of Dilaudid. In one health system, it is common to place a subcutaneous butterfly needle, prime the butterfly tubing with Dilaudid 2 mg/mL, and then provide intermittent doses of 2 mg by adding more Dilaudid to the tubing. While the slow absorption of the drug may be preferred, it is a highly unpredictable rate of absorption that could lead to over sedation and underventilation. A secondary concern is the lack of security for a large amount of controlled drug. The approach described is not unlike attaching a syringe of narcotic to a running IV, leaving the syringe unattended (see the previous blog). Leaving the butterfly with Dilaudid unattended creates an opportunity for drug diversion by a healthcare worker as well as a patient visitor.
Healthcare financing and delivery may be vastly different than the US, but the concepts of access and opportunity leading to drug diversion don’t change. There is much to be learned and shared by healthcare professionals on both sides of the border, because drug diversion is an international crisis.
1 Amanda Lowe, BScFS, (Hons), MSc, Michael Hamilton, MD, MPH, Julie Greenall BScPhm MHSc, Jessica Ma, BScPhm, Irfan Dhalla, MD, MSc, and Nav Persaud, MD, MSc. Fatal overdoses involving Dilaudidone and morphine among inpatients: a case series. CMAJ Open. 2017 Jan-Mar; 5(1): E184–E189